09050010CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
10910 WUNDERLICH DR
JSC CONSTRUCTI
OWNER'S NAME:
GENERAL
PERbAL'r ISSUE DATE
PHONE:
S'k&AWN15 CONTROL NO,
(408) 221-1005
ARCHrIECT/F.NGINEER:
BURRING PERMIT rNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fora and effect.
RMDL BTHRM(37)RPLC FXTRS& TILES
License Class Lie, 1
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER. DECLARATION
1 hereby alfrm that I am exempt from the Contractors License Law for the
following reason. (Section 7o31S, Business and Professions Code: Any city or county
which requires a permit to construct, slier. Improve, demolish, or repair any nru uirc
prior to its issuance, also requires the applicant for such permit to file 1 signed stalancnt
Ft. Floor Area
Valuation
Am he is licensed pursuant to the pmvWons of the Conuxtt>rs Lame Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is mvmpt therefrom and the basis for the alleged exemption. Any violation of
12 0 0 0
APN Number
Occupancy e
p y �p
Section 70315 by any applicant for a permit subjects tho applicant to a civil penalty of
not more thanve hundred dollar (SSOO)-
five
37522004 .00
[IL as owner of the property, or my employees with wages as their sole antprn»tion,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Contractors License Law does net apply to an owner a
property who bads or improves thereon, and who does such work himself ar thiough his
awn employar, provided that such improvements are not intended or offered for sale, u.
however, the building or improvement is sold within one year of completion, cite owner -
builder will have the burden of proving that he did not build or Improve for purpose or
sale
L as owner or the property. am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The ContractoA LI-
ccau Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
L.i¢nse Law.
P C far this reason
�ml'�(J
Owner 1'� G..�I.6t L/"— Date 1
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penally of perjury ore of the following declarations:
❑ I hsve and will maintain a Certificate of Consent to self-insum for Wortcfs Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
❑ I have and will maintain Workers Compertualon Insurance, u required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
.
My Workers Compenaauon Insurance carrier and Policy number are:
Carrier. Policy No_
CERTIFICATE OF NE PTLON FROM WORKERS
COMPENSATION INSURANCE
(rhis section need rat be completed if the permit ts for one hunted dollars ($100)
or Icsa.)
I certify that in the perfornao= of the work for which this permit is issued, I shall not
employ any person in any manner so u to= sub" t to the Workers Comperation
Laws of Califs iL Date !w e ��c
Applies- f1Z1LAr� ,
NOTICE TO APPLICANT. If, alter making this Certificate of Exemption, you should
become subject to the Workees Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be defined revoked
CONSTRUCTION LENDING AGENCY
I bereby affirm that true is a construction lending agency for the performance or
the work for which this permit Is Issued (Sex. 3097, Civ. C.)
Lender's Name
,
[.enders Address
I certify that i have read this application and state that the above Wormatun Is
corccL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise rep.ematives or this city to enter upon the
above -mentioned properly for mspectlon purposes.
(Ric) agree to eve, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
9i4c�
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date `�' -"S
SOURCE REGULATIONS.
Re -roofs ------
—
Type of Roof
Palk 04--- tP'` A-y J 1 L" q
Signature of Appliant/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
WIB Use applicant or future building occupant store or handle hrurdous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section25532(a)7
[:]YesNo
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will ere applicant or Future building occupant use equipment or devices which
emit harardous air contaminants u defined by the Bay Area Air Quality Managcmew
all new materials for inspection.
Disuict7
❑ Yes ❑ No
I have iced the bvardo s materials mquhcmenis under Chaper6.95 of the C1li(or-
oua Hcalth& Safety Cade„ Sections 25505.25533 and 25534. I understand thatlf the building
does not currently have a tenant. that It is my responsibility in notify the occupant of the
requirements which must be met prior to issuance of a crrtifiate of occupancy.
Signature Of Applicant Date
All roof coverings to be Class n" or better
Date
o6r�� ori7zd agent